Definition of concussion*A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

A direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.

The rapid onset of short-lived impairment of neurologic function that resolves spontaneously.

Neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.

A graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that, in a small percentage of cases, post-concussive symptoms may be prolonged.

No abnormality on standard structural neuroimaging studies is seen in concussion.

With school sports underway, you may be seeing an increase in concussion evaluations for student athletes. As of July 1, Indiana law now requires players to be pulled from an athletic activity if a head injury or concussion is suspected. They cannot return to play unless they are evaluated and cleared by a health care provider.

"The law places the burden of return-to-play following concussion on health care personnel and, thereby, relieves schools and coaches from the decision to allow kids to return to play," said Stephen Simons, M.D., chair of the ISMA Commission on Sports Medicine.

Purpose of the lawAccording to the American Academy of Neurology, concussions account for 10 percent of all high school sports injuries, and 40 percent of high school athletes return to play too early.

“Head injuries are more subtle, so it is important for a physician to evaluate an athlete the first time,” advised David Welsh, M.D., ISMA past president and team physician for Batesville schools. “The next hit can result in more dramatic injuries. I have seen this first hand.”

In response, the ISMA Commission on Sports Medicine supported the Indiana High School Athletic Association’s (IHSAA) guidelines two years ago that established when athletes could return to play after a head injury.

What the law means to youThe law states that players suspected of being injured cannot return to play until they have been evaluated by a licensed health care provider trained in evaluation and management of concussions and head injuries and receive a written clearance from that evaluating provider.

ISMA General Counsel Julie Reed noted some legal protections are available for certain physicians who evaluate these athletes.

“Specifically, the law provides civil immunity for volunteer or uncompensated health care providers who in good faith authorize an athlete to return to play. But the immunity will not apply to anyone who makes such a determination without meeting the law's qualifications to do so,” explained Reed. "So, they have to be licensed and trained in the evaluation and management of concussions and head injuries."

Left to right: ISMA members Ed Negovetich, M.D.; David Welsh, M.D.; and Thomas Brown, M.D., are Batesville High School team physicians, serving with athletic trainer Eric Fledderman.

Diagnosis tipsHank Feuer, M.D., team neurosurgeon for the Indianapolis Colts since 1984, developed a practical, user-friendly evaluation card for sideline use. The tool can help diagnose a concussion by assessing a player's orientation, memory, concentration, balance and symptoms. It also offers recommendations for close follow-up of changing signs and symptoms.

Dr. Feuer provided these tips:

Watch player movement on the field after the hit, i.e. getting up slowly or staggering.

Don't assume a concussion has occurred by how the hit to the player looked, or how the crowd reacted; assessment is necessary.

If a concussion is suspected, the helmet must be taken away and the player must be removed from competition and evaluated in an area without distractions.

“A complete evaluation takes six to eight minutes, but doing it the right way is critical and may save a player from many weeks off in the future," Dr. Feuer advised.